MEDICARE: KATHRYN L SPORS APRN, FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	161498-30	WI
2	363LF0000X	Family Nurse Practitioner	5367-33	WI

General Provider Information

NPI Number	:	1952743072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN L SPORS APRN, FNP

Provider Business Mailing Address
First Line	:	147 W ROCKWELL ST
Second Line	:
City	:	JEFFERSON
State	:	WI
Zip	:	53549-2048
Country	:	US
Telephone Number	:	920-674-6255
Fax Number	:	920-674-5288

Provider Business Practice Location Address
First Line	:	1225 REMMEL DR
Second Line	:
City	:	JOHNSON CREEK
State	:	WI
Zip	:	53094-8511
Country	:	US
Telephone Number	:	920-674-6255
Fax Number	:	920-674-5288

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2013
Last Update Date	:	04/06/2020

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